National Tobacco Control Programs Work Plan Template

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Overview

Home Page
Prevention
Secondhand Smoke
Cessation
Mass Reach Communications
Survelliance & Evaluation
Infrastructure, Admin & Mngmt

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Sheet 1: Home Page

						Form Approved OMB No. ####-#### Exp. Date M/D/YYYY
National Tobacco Control Programs
(DP15-1509) Work Plan Template
		[Choose your state name…]
			The following navigation bar is available on all worksheets
			Click a tab to jump to the corresponding sheet:
Instructions:
You may use this template to prepare a work plan for NTCP. Please refer to the supplemental guidance document for more information.
Notes on Data Entry: All light yellow cells are available for user input. Conditional formatting may highlight cells red if values are missing,
not valid, or violate program rules.
Technical Support:
If you need technical support at any time, please send an email with a detailed description of your need to the following address:
[email protected]
Public reporting burden of this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN:PRA ([OMB#]).

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Sheet 2: Prevention

	Goal 1
	Prevent initiation among youth and young adults.
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	Implement flavor bans and other product sales restrictions (e.g., size restrictions)
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
		National Networks
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
		National Networks
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
	National Networks
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 7 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 8 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
	National Networks
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 9 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month

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Sheet 3: Secondhand Smoke

	Goal 2
	Eliminating nonsmokers’ exposure to secondhand smoke.
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month

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Sheet 4: Cessation

	Goal 3
	Promoting quitting among among youth and young adults.
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month

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Sheet 5: Mass Reach Communications

	Mass Reach Communications
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels increase reach:
	Race/Ethnicity
	Please choose the type of media planned for this strategy:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy, including any key messages in your campaign, if known.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels increase reach:
	Please choose the type of media planned for this strategy:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy, including any key messages in your campaign, if known.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels increase reach:
	Please choose the type of media planned for this strategy:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy, including any key messages in your campaign, if known.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month

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Sheet 6: Survelliance & Evaluation

	Surveillance and Evaluation
	Project Period Objective 1
	Project Period Objective 2 (Optional)
	Strategy 1
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month

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Sheet 7: Infrastructure, Admin & Mngmt

	Infrastructure, Administration and Management
	Project Period Objective 1
	Project Period Objective 2 (Optional)
	Strategy 1
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
	Populations of Focus: Within this strategy, will you address Goal 4: "identify and eliminate tobacco-related disparities among population groups"?
	If "yes", indicate the population(s) of focus for the strategy:	Indicate if you will be using any of the following channels to increase reach:
			Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.	Population Description: Specify the population of focus referenced in the categories checked in the “Population of Focus” above.	Specify the TCP position or partner responsible for this activity.	Start Month	End Month